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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 38  |  Issue : 1  |  Page : 25-29

Life threatening hyperkalemia necessitating temporary cardiac pacing and dialysis in elderly patients


1 Department of Cardiology, SKIMS, Soura, Srinagar, Jammu and Kashmir, India
2 Department of Medicine, SKIMS Medical College, Srinagar, Jammu and Kashmir, India
3 Department of Anesthesiology, SKIMS, Soura, Srinagar, Jammu and Kashmir, India
4 Department of Nephrology, SKIMS, Soura, Srinagar, Jammu and Kashmir, India

Date of Submission23-Nov-2019
Date of Decision23-Dec-2019
Date of Acceptance30-May-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Muzafar M Wani
Nik-Nax, 6 Polo-View, Srinagar, Kashmir - 190 001, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IOPD.IOPD_6_19

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  Abstract 


Background Many elderly hypertensive patients are on cardio/reno protective medications (ACEIs, ARBs, β blockers & K sparing diuretics), which may precipitate or worsen hyperkalemia in them. Given its potential life threatening nature, identifying such patients is imperative. Rarely emergency temporary cardiac pacing may be required to thwart cardiac arrest while K is being lowered by extracorporeal removal. In many resource-constrained settings HD to lower K quickly is not always available.
Materials and Methods We describe the profile of 26 patients over a three year period who besides medications & dialysis needed temporary cardiac pacing because of severe hyperkalemia.
Results: The mean age of these 26 patients (17 males, 9 females) was 64+/-11 years. 12 (46%) had diabetes mellitus. On admission, the mean serum K was 6.7 ± 1.4 mmol/L, mean serum creatinine was 2.8 ± 1.6 mg/dL, mean arterial pH was 7.1 ± 0.5 and the mean plasma bicarbonate was 12 ± 4 mmol/L. The main causes for acute kidney injury (AKI) and hyperkalemia were dehydration (n = 14) and worsening heart failure (n = 7) with concomitant use of ACEIs, ARBs, β blockers, K sparing diuretics either alone or in combination. 22 patients received PD, two HD, while two received both. Six patients were admitted to the ICU, two of whom died. The duration of hospitalization ranged from 1-12 with a mean of 7 days. The patients in the drug induced hyperkalemia group who required pacing were elderly, had been on a combination of K elevating medications, were more likely to have DM and had a longer hospital stay compared to those who had hyperkalemia but did not require cardiac pacing.
Conclusion: A combination of ACEIs, ARBs, β blockers & K sparing diuretics should be used with caution in patients who are elderly, have renal insufficiency, DM or heart failure or are at risk for dehydration. In places with limited availability of emergency HD, PD is an effective alternative for lowering serum K.

Keywords: Acute kidney injury, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, complete heart block, hyperkalemia, potassium


How to cite this article:
Lone AA, Bhat TA, Sofi KP, Wani IA, Wani MM, Bhat MA. Life threatening hyperkalemia necessitating temporary cardiac pacing and dialysis in elderly patients. Indian J Perit Dial 2020;38:25-9

How to cite this URL:
Lone AA, Bhat TA, Sofi KP, Wani IA, Wani MM, Bhat MA. Life threatening hyperkalemia necessitating temporary cardiac pacing and dialysis in elderly patients. Indian J Perit Dial [serial online] 2020 [cited 2021 Jul 31];38:25-9. Available from: https://www.ijpd.org.in/text.asp?2020/38/1/25/305756




  Introduction Top


Plasma potassium (K) is maintained within narrow limits of 3.5-5 mmol/L.[1] Hyperkalemia is a potentially lethal electrolyte disturbance, associated with adverse clinical outcome and its prompt recognition and expeditious treatment can be lifesaving.[1],[2] Severe hyperkalemia (K ≥ 6.5mmol/L) is a medical emergency requiring hospitalization, monitoring and immediate treatment.[3]

With new guidelines for management of hypertension (JNC 8) promoting use of ACEIs and ARBs, hyperkalemia may become a more common clinical event than before.[4] Hyperkalemia develops in about 10% of patients initiated on ACEIs or ARBs and usually occurs in elderly patients with concurrent risk factors (diabetes, impaired renal function, other K elevating medications).[5],[6],[7] Potassium homeostasis is usually maintained till late in the course of CKD, till GFR falls to 15ml/min (Stage 4/5).[8],[9] Many elderly patients have concurrent hypertension, renal insufficiency and associated cardiovascular diseases and are on cardio-protective and reno-protective medications like ARBs, ACEIs and K sparing diuretics which may precipitate hyperkalemia even at earlier stages of CKD. Diet rich in K also contributes to hyperkalemia in some.[10]

Hyperkalemia is associated with ECG abnormalities and rarely severe cardiac rhythm abnormalities (CHB) necessitate temporary cardiac pacing.[11] Temporary cardiac pacing as a temporizing measure in treatment of severe hyperkalemia is seldom required in the developed world because early detection and readily available hemodialysis ensure that serious cardiac rhythm abnormalities are not seen. But such is not the scenario in the developing and poorer world. In developing region like ours, referral of patients may be delayed that prolongs and worsens hyperkalemia which may affect cardiac conduction especially in the elderly, which may cause CHB and as such necessitate temporary cardiac pacing in some. Some cases with refractory hyperkalemia will need extracorporeal removal of K through hemodialysis or peritoneal dialysis. However in developing countries, the facilities of hemodialysis are scant and emergency hemodialysis may not be available at many places. Moreover, the hemodynamic instability in some of these patients may not allow them to be handled by HD and with non- availability of continuous forms of renal replacement therapy (CRRT), in such circumstances, acute peritoneal dialysis may be the only lifesaving modality available.[12]

We did this retrospective analysis of 26 patients who over a three year period had been admitted with severe hyperkalemia which besides medical management and dialysis, required temporary cardiac pacing due to complete heart block (CHB).


  Materials and Methods Top


We performed a retrospective study of 26 patients who presented with drug induced severe hyperkalemia associated with CHB necessitating temporary cardiac pacing, besides requiring measures to reduce 'K' with medications and acute peritoneal dialysis (22 patients) or hemodialysis (2 patients) or both (2 patients). The period of study was January 2013 to December 2015, during which majority of the patients received PD because of limited availability of emergency HD. Over the study period, demographic characteristics, etiology of hyperkalemia and hospital outcome were assessed. A comparison with patients who were having hyperkalemia and were dialyzed, but did not require pacing was also done as a sub analysis.

Peritoneal dialysis, after fixing a bedside rigid peritoneal dialysis catheter, was performed manually using commercially available K free PD solutions with 1.7% glucose. One exchange included instilling 2 L of PD fluid into the abdominal cavity, followed by a dwell time and later removal of the fluid. The time taken for one exchange was approximately 60 minutes (20 minutes to instill, 20 minutes of dwell time and 20 minutes of removal). Temporary pacing was done in Cath lab by the on duty cardiology fellow via a trans-femoral cutaneous approach.

Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 11.5.0 from SPSS Inc., Chicago, IL. Data was expressed as mean +/- SD, unless specified otherwise. Continuous variables were compared using Student's t test whereas categorical variables were compared Chi square test, where the data was not skewed Mann-Whitney U test was used for comparing continuous variables. P value of < 0.05 was taken as significant.


  Results Top


As seen in [Table 1], about 30% of the annual admissions to the Department of Nephrology are through the emergency department; hyperkalemia is the reason for about 10% of all and more than a third of emergency admissions. Some of the hyperkalemic patients who do not respond to conservative measures or have other indications, undergo dialysis which, in most of the emergency cases was acute peritoneal dialysis during the study period [Table 2]. Out of the 750 temporary cardiac pacing procedures done in the Department of Cardiology during the study period, in 26 (3.46%) patients it was done because of hyperkalemia induced CHB. The temporary pacemaker (TPM) was required for an average of 2 days (1-6 days).
Table 1: Patients who present with hyperkalemia

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Table 2: Acute peritoneal dialysis data at SKIMS

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These 26 patients presented with varying clinical presentations like altered sensorium, presyncope/syncope, odema, dyspnea and features due to inter current illness like fever, vomiting, diarrhea and oliguria. Some were referred with a high serum K and ECG changes of CHB from periphery. The demographic data of our patients is shown in [Table 3]. The mean age of the 26 patients (17 males, 9 females) was 64+/- 11 years. The mean serum potassium was 6.7 +/- 1.4 mmol/L and the mean serum creatinine was 2.8 +/- 1.6 mg/dL. The mean arterial pH on admission was 7.1 +/- 0.5 and the mean plasma bicarbonate was 12 +/- 4 mmol/L. The main causes for acute kidney injury were dehydration (n = 12) and worsening heart failure (n = 7) and concomitant use of ACEIs, ARBs, β blockers, K sparing diuretics either alone or in combination (in all patients) [Table 4]. Of the 26 patients, 22 received PD, 2 received HD while 2 others received both PD and HD. Six patients were admitted to the ICU, two of whom died. Both of these patients had sepsis, hyperosmolar hyperglycemic state with multi organ dysfunction. The length of hospitalization ranged from 1-12 days with an average of 7 days. The patients who required temporary cardiac pacing were older, had more severe hyperkalemia and more likely to have diabetes and longer hospital stay compared to patients managed with PD without pacing [Table 3]. Of the 24 patients who normalized their serum K after the necessary intervention, 18 reverted to normal sinus rhythm, 4 had right bundle branch block (RBBB) and 2 had left bundle branch block (LBBB).
Table 3: Demographic data of hyperkalemic patients

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Table 4: Etiology of acute kidney injury and hyperkalemia,treatment and outcome

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  Discussion Top


Increase in life expectancy together with increased prevalence of hypertension and diabetes has resulted in increasing use of cardio and reno- protective medications in the elderly. Some of these elderly patients have a chance of developing hyperkalemia, which seems to be on the rise, as is evident in the rise of the patients admitted over last 3 years [Table 2]. About 10% of outpatients develop hyperkalemia within a year after prescription of ACEIs or ARBs; most of such patients have associated risk factors like diabetes, dehydration and concurrent use of other K elevating medications.[5],[6],[7],[13],[14],[15] Moreover, many CKD patients who have a propensity of developing hyperkalemia, may be taking medications which worsen their hyperkalemia and lead to rhythm disturbances (CHB) rarely necessitating cardiac pacing in them.[10],[13]

During the study period about 10% of all admissions to our department were because of hyperkalemia and there has been a marginal increase in the admission percentage due to drug induced hyperkalemia [Table 1], likely because of multiple K raising antihypertensive medications being prescribed to this group. Many of our CKD patients who reported to emergency department during night with advanced uremic complications (refractory metabolic acidosis, refractory hyperkalemia, encephalopathy, volume overload) underwent intermittent peritoneal dialysis, due to limited facility of routine HD in the night.

Many of these hyperkalemic patients are managed with potassium restricted diet, withdrawal of the offending drug and use of medications to lower K acutely (insulin-glucose, sodium bicarbonate, β agonist nebulization).[16] However, such measures cause only modest reductions in K, therefore additional measures are required in most patients, especially those with ECG abnormalities, which includes extracorporeal removal of K.[12],[16] When rapid correction of hyperkalemia is desired, hemodialysis (HD) is the method of choice, but rebound hyperkalemia (which may precipitate ventricular arrhythmias) is an issue with it.[14],[16] Peritoneal dialysis (PD), while not very effective in acute settings given a much slower removal of K, does have a role in elderly, sick patients who often have hemodynamic instability that precludes HD.[12]

During the study period 1314 patients underwent intermittent peritoneal dialysis in our department, with more than a third (456; 34.7%) of them being dialyzed for drug induced hyperkalemia. Of the patients requiring dialysis for drug induced hyperkalemia, 5.7% (26 out of 456) had hyperkalemia related CHB requiring temporary cardiac pacing. The HD facilities at our centre during the period of the study were limited and emergency HD particularly during night was usually not readily available. Due to limited availability of HD together with hemodynamic instability in some, most of these patients (24/26) underwent PD as the modality to reduce the elevated K. Two patients underwent HD and 2 who did not respond to PD also underwent HD. As depicted in [Table 5] the number of PD exchanges (1.7% of 2 liters each) given varied from a minimum of 6 to a maximum of 20. The serum K monitored frequently, normalized in 30% of patients within 6 exchanges, in additional 50% in 15 exchanges while the remaining 20% required 20 exchanges which included patients with uremia and severe acidosis. Patients with hyperkalemia who required temporary cardiac pacing (26) were older, had more severe hyperkalemia and were more likely to have diabetes and longer hospital stay compared to those who did not require temporary pacing (430) [Table 3].
Table 5: Peritoneal dialysis data of 26 patients

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  Conclusion Top


An average of 10 patients with life threatening cardiac rhythm abnormalities (CHB) secondary to severe hyperkalemia and requiring temporary cardiac pacing besides dialysis get admitted to our services annually. This underscores the importance of identifying patients prone to develop serious hyperkalemia with medications. Caution is required while prescribing medications impacting K homeostasis and judicious monitoring of serum K in patients receiving such medications is mandatory. While HD, if available, is the first choice in stable patients, in resource poor settings acute PD can be an effective alternative in management of severe hyperkalemia. Until uninterrupted access to HD becomes a reality, PD can serve as an effective second choice in resource limited settings as shown by this and some other studies.[12]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Palmer BF. A physiologic-based approach to the evaluation of a patient with hyperkalemia. Am J Kidney Dis 2010;56:387-93.  Back to cited text no. 1
    
2.
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Schepkens H, Vanholder R, Billiouw JM, Lameire N. Life-threatening hyperkalemia during combined therapy with angiotensin-converting enzyme inhibitors and spironolactone: An analysis of 25 cases. Am J Med 2001;110:438-41.  Back to cited text no. 6
    
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Reardon LC, Macpherson DS. Hyperkalemia in outpatients using angiotensin-converting enzyme inhibitors. How much should we worry? Arch Intern Med 1998;158:26-32.  Back to cited text no. 7
    
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Sarafidis PA, Blacklock R, Wood E, Rumjon A, Simmonds S, Fletcher-Rogers J, et al. Prevalence and factors associated with hyperkalemia in predialysis patients followed in a low-clearance clinic. Clin J Am Soc Nephrol 2012;7:1234-41.  Back to cited text no. 8
    
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Einhorn LM, Zhan M, Hsu VD, Walker LD, Moen MF, Seliger SL, et al. The frequency of hyperkalemia and its significance in chronic kidney disease. Arch Intern Med 2009;169:1156-62.  Back to cited text no. 9
    
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Perazella MA, Mahnensmith RL. Hyperkalemia in the elderly: Drugs exacerbate impaired potassium homeostasis. J Gen Intern Med 1997;12:646-56.  Back to cited text no. 10
    
11.
Montague BT, Ouellette JR, Buller GK. Retrospective review of the frequency of ECG changes in hyperkalemia. Clin J Am Soc Nephrol 2008;3:324-30.  Back to cited text no. 11
    
12.
Ansari N. Peritoneal dialysis in renal replacement therapy for patients with acute kidney injury. Int J Nephrol 2011;2011:739794.  Back to cited text no. 12
    
13.
Espinel E, Joven J, Gil I, Suñé P, Renedo B, Fort J, et al. Risk of hyperkalemia in patients with moderate chronic kidney disease initiating angiotensin converting enzyme inhibitors or angiotensin receptor blockers: A randomized study. BMC Res Notes 2013;6:306.  Back to cited text no. 13
    
14.
Takaichi K, Takemoto F, Ubara Y, Mori Y. Analysis of factors causing hyperkalemia. Intern Med 2007;46:823-9.  Back to cited text no. 14
    
15.
Jaman PR, Kehely AM, Mather HM. Hyperkalemia in diabetes; prevalence and associations. Postgrad Med J 1995;71:551-2.  Back to cited text no. 15
    
16.
Palmer BF. Managing hyperkalemia caused by inhibitors of the renin-angiotensin-aldosterone system. N Engl J Med 2004;351:585-92.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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